A criminal investigation has been launched by the Health and Safety Executive into the death of a woman at Stafford Hospital in 2007.
The HSE today announced it has started a formal investigation into the death of Gillian Astbury, who died after staff failed to give her vital insulin medication.
Mrs Astbury, who needed daily injections of insulin, slipped into a diabetic coma and died at the scandal-hit trust in April 2007.
The HSE had delayed holding an investigation until the conclusion of the public inquiry into failures at Mid Staffordshire Foundation Trust by Robert Francis QC.
A spokesman for the HSE said today: “We can now confirm that our inspectors have today formally started an investigation.
“Our focus will be on establishing whether there is evidence of the employer or individuals failing to comply with their responsibilities under the Health and Safety at Work Act.”
The Crown Prosecution Service has previously ruled there was insufficient evidence to support manslaughter charges against any individuals in relation to the case, and it was passed to the HSE to consider if there had been breaches of health and safety legislation.
During the public inquiry the HSE admitted its practice was to ignore the law in relation to investigating deaths as a result of “clinical decisions about diagnosis or treatment”, due to a lack of resources to do so. It has since pointed out that it does investigate and prosecute some “exceptional cases” of this type.
The HSE has also said its policy was based on the belief that such cases were addressed by other legislation and regulators. Mr Francis described the situation in his report as a “regulatory gap” which should be closed, and the government last month said it would ensure sufficient resources were available to the HSE.
HSE chief executive Geoffrey Podger said in a statement to HSJ: “HSE’s policy has been not to give priority to investigations under the Health and Safety at Work Act in relation to matters of clinical judgement or care where other legislation and regulatory bodies already deal with these matters.
“The courts have upheld HSE’s right to take into account the use of its resources in deciding which cases to investigate.”
Mr Podger said he believed the government’s proposal for a chief inspector of hospitals employed by the CQC to be able to refer cases to the HSE would “help close the regulatory gap” and “provide certainty and clarity for the public, for the services and for regulators”.
Evidence about Ms Astbury’s death was heard by the public inquiry, which identified a failure by NHS West Midlands, and specifically its head of nursing Peter Blythin, to properly investigate what happened.
Despite details of the incident being emailed to Mr Blythin, now director of nursing at the NHS Trust Development Authority, the strategic health authority took no action between July 2007 until January 2010.
It only asked the Mid Staffordshire trust for details of what action had been taken in 2010, after an inquest concluded the failure by nursing staff to administer Ms Astbury with her insulin amounted to a “gross failure to provide basic care”.
Some nurses at the trust were not informed Ms Astbury was diabetic and others claimed they were too busy to check her notes.
Despite her high blood sugar levels no action was taken by nursing staff and the jury at the inquest into her death found failures in the “implementation, monitoring and management of the systems in place”.
They added: “Nursing facilities were poor, staff levels were too low, training was poor, and record-keeping and communications systems were poor and inadequately managed.”
Following the HSE announcement Julie Hendry, director of quality and patient experience at the Mid Staffordshire trust, apologised for the “appalling care Ms Astbury received”. She added: “A full investigation into her care and treatment was carried out.”
She said: “The recommendations from that investigation were implemented. Actions included raising staff awareness about the care of diabetic patients and improving the information and system for nurse handovers.
“In 2010 we reviewed Ms Astbury’s dreadful care and as a result, disciplinary action was taken.
“We will of course cooperate fully with the Health and Safety Executive’s investigation.”
Information supplied to HSJ